Be Prepared for Battle When Entering Utilization Reviews

Utilization reviews frequently are contentious discussions between payers and provider organizations. Managed care organizations make their determinations based on the information they receive, though, and if providers allow the tail to wag the dog, they have no one but themselves to blame, Promises Behavioral Health CEO Kirk Kureska said on Tuesday at the Treatment Center Investment & Valuation Retreat.

During utilization reviews, treatment centers need to be able to provide clear and compelling evidence that the client is a harm to him/herself, others or property. They also need to be prepared to explain why the client can’t function outside of the structure proposed or benefit from a lower level of care, Kureska said.

“Have your plan and defend your plan,” Kureska said. “If your facility is truly as good as you say it is, back it up. Your business counts on it to grow, and you have a patient demanding that you’re doing your job.”

Kureska covered a variety of ways organizations can prepare their cases to secure coverage for the maximum number of days in treatment available.

• Create individualized treatment plans. Kureska said he will meet with staff and read the treatment plan for a certain patient, covering up the patient’s name, and then ask staff whose treatment plan he has presented. The point is to make sure treatment plans are truly individualized for each patient because cookie-cutter programs don’t move the needle with managed care. “If you are struggling with why you can’t get authorization, it’s because you sound like everybody else out there,” Kureska said. “Not every patient is the same.”
• Stick to facts, not “psychobabble.” Get to the point about the medical necessity for the patient to receive your care, Kureska said.
• Ask for as many days as possible. “If you don’t ask, you won’t get it,” Kureska said.
• Know applicable laws and the rules of your working agreement with a managed care company. Violating rules trigger crippling administrative denials.
• Never be afraid of the fight. Patients are counting on you to fight for their right to treatment, Kureska told attendees.
• Be prepared and create a culture of documentation. Reviewers often will ask for notes to support claims made during utilization reviews, Kureska said. Failing to produce them upon request will open the door for a denial. “I don’t report things that aren’t in the record,” Kureska said. “If it’s not on the record, it never happened.”

Sophisticated strategies for success

Sophistication was a recurring theme for a diverse collection of panelists who convened in the early afternoon session on Tuesday at TCIV.

On marketing: Raul Ruelas, owner of San Antonio Recovery Center, said the single biggest factor in his organization experiencing 200% growth in its business over the past five years has been engaging with a marketing agency to refine its outreach, starting with an SEO campaign. It was a painful move at first because the investment didn’t provide immediate returns, Ruelas said, but it has ultimately paid off. San Antonio Recovery Center now ranks No. 1 in organic search results on Google for 225 terms in the San Antonio metroplex, and more than 50% of the company’s business comes from its online marketing.

On private equity: Christal Contini, member and co-chair of the mergers and acquisitions practice at McDonald Hopkins, says private equity is doing its due diligence on the behavioral healthcare market and provider organizations looking for investment dollars need to be prepared to explain how they separate themselves from the pack. Private equity firms are prepared to move quickly, and they have the sophistication to hold providers to higher standards. The faster providers can provide desired information, the more likely deals are to get done, Contini said.

On food service. Daniel Natterman, senior vice president and chief growth officer at Unidine, said the days of mom-and-pop food service operations are becoming antiquated. Food service, Natterman added, is an often-overlooked, but critical cornerstone to driving quality of care for addiction treatment providers, as many patients enter treatment malnourished. Having a food service partner that understands allergies and other dietary needs will “become table stakes in the next three to five years,” he said.

On data. Kirk Monroe, president of Lightning Step Technologies, said a lack of standardization among platforms is hurting providers’ attempts to produce worthwhile outcomes data. Being able to have one system that requires patient data one time can improve efficiency dramatically, Monroe said.